By Dr. David Mayer

First Posted at Educate the Young on 5/28/2013

David Mayer MD, Vice President of Quality and Safety for MedStar Health

David Mayer MD, Vice President of Quality and Safety for MedStar Health

Over the past year, we have shared numerous posts on the characteristics of High Reliability Seeking Organizations (HRSO), and their drive to zero serious safety events (see Travel Buddies…,Reporting on Near Misses…Mindlessness vs Mindfulness, and more). A number of healthcare organizations who have been on this HRSO journey for a number of years have experienced remarkable decreases in preventable patient harm across their system.

MedStar Health (MSH) is excited to be working with Healthcare Performance Improvement (HPI) on our own HRSO journey. By layering on the different “competencies” shown in HPI’s “Road to Reliability” diagram, it has been their experience that client hospitals can achieve higher levels of reliability.  The diagram also highlights why we believe we can achieve a high level “Reliability Culture” at MedStar by integrating human factors engineering on top of all this work through our very own National Center for Human Factors Engineering led by Terry Fairbanks MD and his team of clinical care engineers.

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When I first saw this diagram, however, I immediately wondered what would happen to to the outcome curve if a fourth “competency”, patient engagement, was added. Was there a way to bring high reliability training and tools to our patients and families? In my mind, the best way to start this conversation was to have Marty Hatlie, JD, CEO-Project Patient Care, President-Partnership for Patient Safety, and one of our Patient and Family Advisory Council for Quality and Safety (PFACQS) members, join us for an all-day High Reliability Boot Camp so he could add the patient’s voice into the training session, as well as share his thoughts with other PFACQS members. Carole Hemmelgarn, another of our PFACQS members, has already been working with the Children’s Hospital HRSO HEN network. Marty, as he always does, added a number of unique perspectives and new ideas to the high reliability discussions throughout the day, and those that have followed.

Here are a few of Marty’s thoughts that need to be shared. First, Tracy Granzyk, in her recent post, High Reliability Boot Camphighlighted three things patients want: (a) Don’t harm me, (b) Heal me, and (c) Be nice to me. Marty astutely added two additional things patients want: (d) Listen to me, and (e) Give me the opportunity to engage and partner in my care.

Marty also pointed out that several of the safety and resilience training tools used by caregivers could also be customized and given to patients and family members. There would need to be some basic training but we believe this could be accomplished. HPI’s Judy Ewald, who was leading the day-long training session, underscored this point in sharing how she uses two tools – SBAR (Situation, Background, Assessment and Recommendation) and STAR (Stop, Think, Act and Review) – in her personal life. Additionally, if we have Safety Coaches for our caregivers, why couldn’t we create Safety Coaches for our patients and families? Thanks to Marty, and to all those who added reminders on what patients want as we seek high reliability, I came away excited that we could take HPI’s outcomes curve on this diagram to a higher level.